Medical Surgical Nursing Concepts and Practice Test Bank

Correct Answer: A

Rationale: Morning headaches that extend into the neck and subside as the day progresses can be indicative of elevated blood pressure, which is a common cause of morning headaches. Increased blood pressure can cause headaches that are usually worse in the morning due to the body's natural circadian rhythms. Monitoring the client's blood pressure and assessing for other signs of hypertension would be important in this case. Tachycardia, otitis media, and swollen lymph nodes are less likely to be associated with the described symptoms.

Correct Answer: C

Rationale: Bladder cancer is a health problem that can result from a combination of genetic and environmental factors. Genetic mutations can predispose individuals to developing bladder cancer, while environmental factors such as smoking, exposure to certain chemicals, and chronic bladder irritation can also contribute to the development of the disease. Hematuria (blood in the urine) can be a symptom of bladder cancer, but it is not specific to this type of cancer and can also occur in other renal system disorders. Incontinence and kidney infections are not typically associated with genetic predisposition as much as bladder cancer.

Correct Answer: C

Rationale: For a patient experiencing end-stage renal disease, it is important for the nurse to discuss the advantages and disadvantages of different renal replacement therapies. This goal is crucial to help the patient make informed decisions about their treatment options. Patients with end-stage renal disease often face choices between hemodialysis, peritoneal dialysis, and kidney transplantation. Understanding the advantages and disadvantages of each therapy can empower the patient to actively participate in their treatment decision-making process and achieve the best possible outcomes for their health. It is essential for the nurse to promote patient education and shared decision-making to ensure that the patient's preferences and values are respected throughout their care journey.

Correct Answer: D

Rationale: Disseminated intravascular coagulation (DIC) is a serious condition characterized by both excessive clotting and bleeding throughout the body. The primary goal of care for a client with DIC is to manage and balance the clotting and bleeding tendencies. A key indicator of successful care for a client with DIC is the absence of bleeding, as this suggests that the coagulation process has been stabilized and there is no ongoing clot breakdown leading to bleeding. Monitoring for signs of bleeding, such as petechiae, purpura, ecchymosis, hematuria, and gastrointestinal bleeding, is essential in evaluating the effectiveness of care in a client with DIC. Therefore, the absence of bleeding is the most significant finding that indicates successful care in a client with DIC.

Correct Answer: D

Rationale: Phantom limb sensation is a common phenomenon where a patient perceives sensations such as cramping, itching, or pain in the limb that has been amputated. This occurs because the brain continues to receive signals from the nerves that originally innervated the amputated limb, leading to the perception of sensation in the absent body part. In this case, the patient's complaint of toes cramping in the amputated foot is indicative of phantom limb sensation rather than contractures, attention-seeking behavior, or chronic stump pain. It is important for the nurse to educate the patient about this phenomenon and provide appropriate support and reassurance.